Knee Pain: Treat with Lifestyle Changes

A review of 47 studies on 22,037 patients with knee osteoarthritis treated for at least 12 months showed no clear difference in controlling long-term pain between medications and placebos (JAMA, 2018;320(24):2564-2579). There was a slight time-limited pain control with a non-steroidal (celecoxib) and glucosamine.

With the exception of immune suppressants that have lots of serious side effects, medications and health supplements do not prevent progressive damage to joints and are used only to help lessen pain. The list of medications for osteoarthritis is huge, including:
• nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and other pain medicines
• antioxidants
• bone strengtheners such as bisphosphonates
• joint injections such as hyaluronic acid and corticosteroids
• chemicals found in cartilage such as glucosamine and chondroitin sulfate
• disease-modifying agents such as cindunistat or sprifermin

Know the Cause of Your Joint Pain
If you do not already have a diagnosis, check with a doctor to see if you have rheumatoid arthritis, psoriatic arthritis, gout, reactive arthritis from an infection or some other known cause of joint pain. If you have sudden locking of your joint that gets better and then recurs, you may have “joint mice,” loose pieces of cartilage that slip between your cartilage to cause horrible pain. This can usually be cured by removing the loose pieces with arthroscopic surgery.

Osteoarthritis is the most common cause of chronic and progressive joint pain. It can eventually destroy the cartilage in joints, and is among the most prevalent chronic diseases and a leading cause of disability worldwide (JAMA, 2018;319(14):1444-1472). Eighty percent of North Americans have X-ray evidence of osteoarthritis by age 65, and sixty percent have significant joint pain. More than 700,000 people in North America have their knees replaced each year, mostly for this condition.

What Causes Osteoarthritis?
A diagnosis of osteoarthritis used to mean that your doctor had ruled out other known causes of knee pain and had no idea what was causing your joint pain. Now we know that people with osteoarthritis have high blood levels of galectins that turn on a person’s immune system to cause inflammation, just as in rheumatoid arthritis or reactive arthritis (J of Immunology, Feb 15, 2016;196(4):1910-1921). If your immune system stays overactive, the same chemicals and cells that are used to attack germs can attack and destroy the cartilage in your joints.

A review of 68 studies showed that osteoarthritis is associated with everything that increases inflammation, such as obesity, high blood pressure, high cholesterol, diabetes and metabolic syndrome (Rheumatology, May 1, 2018;57(suppl_4):iv61–iv74; Rheumatology, Jan 1, 2016;55(1):16–24), and that this joint pain is reduced temporarily by anything associated with the control of inflammation:
• omega-3 oils in fish
• leafy green foods such as kale, spinach and parsley
• weight reduction in people who are overweight (but not in thin people)
• strengthening and flexibility exercises (Arthritis Care & Research, Dec 5, 2017;69(12) and aerobic exercise (The Knee, January 18, 2018)
• avoidance of smoke
• restriction of alcohol
Several studies have shown that exercise is more effective than surgery (arthroscopic partial meniscectomy) in treating people with knee pain and degenerative meniscal tears (BMJ, July 20, 2016; N Engl J Med, 2013;368:1675-84). See Arthroscopic Knee Surgery is Usually Useless.

Anti-Inflammatory Lifestyle to Treat Osteoarthritis
• Eat an anti-inflammatory diet that includes lots of fruits, vegetables, whole grains, beans, nuts and other seeds, and restricts red meat, processed meats, foods with added sugar, all sugared drinks including fruit juices and fried foods. People who eat an anti-inflammatory Mediterranean-style diet are at reduced likelihood to get osteoarthritis (Clin Nutr, Oct 8, 2016) .
• Lose weight if overweight. Excess weight causes inflammation, and obesity is a major risk factor for osteoarthritis (Int J Obes Relat Metab Disord, 2001;25(5):622-627); Osteoarthritis Cartilage, Oct 27, 2015. S1063-4584(15)01364-3; Arthritis and Rheumatism, Sept 15, 2008;59(9):1207-13). Losing as little as 11 pounds reduced risk of developing knee osteoarthritis among women by 50 percent (Arthritis and Rheumatism, August 1998;41(8):1343-55).
• Move more. Osteoarthritis almost always worsens with inactivity. Exercise increases cartilage quality in osteoarthritis (Med and Sci in Sprts and Ex. Mar 23, 2017), and a review of 55 studies showed that weight bearing exercise reduced pain and improved joint function (British Journal of Sports Medicine, September 24, 2015). Aerobic and strength training for 20 weeks markedly decreased knee pain and increased mobility (Arthritis Care & Research, Aug 30, 2016). A review of six studies of 656 men and women with knee osteoarthritis found that exercise improves symptoms of knee pain in osteoarthritis and that it didn’t make much difference whether the knee exercise program was of low or high intensity (Cochrane Database Syst Rev, 2015 Oct 29;(10):CD010203). However, you need to be guided by pain and always stop if the pain worsens.
• Avoid impact sports. The force of your feet hitting the ground can break off cartilage in your knees. Do not run, jump or participate in sports that involve the strong impact of your foot hitting the ground. Non-impact sports include cycling, swimming, water aerobics and use of machines such as ellipticals or stair-steppers where your feet are supported by the equipment as you move.
More at Lifestyle Changes to Reduce Joint Pain

Use Medications As Needed to Control Pain
It is acceptable to try to control your pain with NSAIDs or other pain medications, but realize that they do nothing to stop progressive joint destruction and do not cure the pain. Take the lowest dose that helps to relieve your pain and use them only when needed.

If the pain becomes so unbearable that it keeps you awake at night, it may be time to consider a knee replacement. However, joint replacements do not last forever; at this time most replacements last about 15 years, so put off the surgery as long as you can. Your surgeon should caution you that replacement joints increase risk for infections because any infection in your body can settle in the replaced joint since it has no local immunity. See my reports on Total Knee Replacement and Partial Knee Replacement (which I do not recommend).

Checked 5/1/23